Fillable Printable Travel History Form - California
Fillable Printable Travel History Form - California
Travel History Form - California
Name: :
Address:
Date of Birth: / /
Home Telephone No.: ( ) Work Telephone No.: ( )
E-Mail Address: Do you have a current passport or visa?
Male
Female
Travel Specics
Today's Date: / /
10-Digit USC ID No.
Ye s
No
Dont' Know
Purpose of Trip:
School Related Study/Work
Pleasure Business Other:
What school?
Countries AND cities to be visited in order of visits Arrival Date Departure Date
A. Have you travelled outside the United States before?
B. Will you be:
Visiting ONLY major cities? If no, explain:
Staying ONLY in Hotels? If no, explain:
Visiting friends and family?
Ascending to high altitudes (>7,000 . or 2,300 meters) in the mountains.
Working in the medical or dental eld with exposure to blood or other body uids?
Working with exposure to animals?
Potentially having sexual contact with new partners?
If yes, where and when?:
Yes No
Yes No
Does your program require the completion of a medical form by a practitioner?
Ye s
No
Departure Date from United States: Return Date to United States:
Ye s
No
Are you currently enrolled in a health insurance plan that covers you while overseas?
What insurance coverage do you currently have?
What will you be doing on this trip?
A pdf online version of this form may be completed at: www.usc.edu/uphc (click forms) and e-mailed as an attachment to: [email protected]
Do you have medical evacuation insurance?
Ye s
No
Travel History Form
Pg. 1 of 2 continued . . .
Engemann Student Health Center • 1031 W. 34th Street, Los Angeles, California 90089-3261 • 213-740-9355
Travel History Form Pg. 2 of 2
Name:
USC 10-Digit ID Number:
ESC: 283 01/2013
Allergies
1. No known drug allergies No known Food allergies
2. Have you had an allergic reaction to any of the following? (please check all that apply)
1. Were you born in the United States? Yes No If no, where?
2. Have you completed the following immunizations? (
Please bring your vaccination record
)
Immunizations
Eggs
Sulfa Drugs (e.g., Bactrim, Septra, Gantrisin)
Antibiotics (e.g., Neomycin, Streptomycin)
imerosal (preservative in contact lens solution)
Chrysanthemums
Quinines (Chloroquine [Aralen], Meoquine [Lariam],
Hydroxycholoroquine [Plaquenil], Primaquine)
Pyrimethamine
Tetracyclines (Doxycycline, Minocin, Minocyclin,
Acromycin, Sumycin)
Other:
1.
2.
3.
Regularly Used Non-Prescription Medications Condition or Reason for Use
3. List regularly used non-prescription medications (
Over-the-counter, herbal, homeopathic, vitamins, etc.
)
1.
2.
3.
Current Prescription Medications Condition or Reason for Use
1. Are you using steroids, receiving radiation therapy or other immunosuppressive chemotherapy?
2. List your current prescription medications and medical condition treated: (include birth control pills)
Medical History
Hepatitis A Yes when: No Not Sure
Hepatitis B Yes when: No Not Sure
Meningococcal Meningitis Yes when: No Not Sure
MMR
(Measles, Mumps and Rubela)
Yes when: No Not Sure
Polio Series Yes when: No Not Sure
Tetanus Yes when: No Not Sure
Typhoid
Yes when: No Not Sure
Yellow Fever
Yes when: No Not Sure
Other: when:
4. Have you been told you have any of the following medical conditions (check all that apply)?
1. Please list additional questions or concerns that you might have regarding your travel? (i.e., Int'l. voltage requirements,
currency exchange, dealing with seasickness, etc.)
Yes No
5. (For Women Only)
a. Last normal menstrual period: b. Are you, or could you possibly be, pregnant?
c. Are you breast-feeding an infant?
Liver Disease/Hepatitis
Lung Disease
Prostate Problems
Psoriasis/
Other
Skin Problem
Psychiatric Problems
Sickle Cell Disease
Stomach Ulcer
Stroke
Thyroid Problems
Other:
Anemia
Asthma
Blood Clotting Problems
Cancer
Depression
Diabetes
Ear Infections Chronic or Frequent
Epilepsy/Seizure Disorder
Eye Problems (Except glasses/contacts)
G6PD Deciency
Gout
Hearing Problem
Heart Disease
High Blood Pressure
High Cholesterol
Hormone Problems
Immune System Deciency
Kidney Disease
Yes No
Family
History
Yes No
Family
History
Yes No
Family
History
Yes No
Yes No
Questions/Concerns
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Engemann Student Health Center • 1031 W. 34th Street, Los Angeles, California 90089-3261 • 213-740-9355
